September 2016 Journal Club with Justin & Casey

Its a new month and that means a new episode of the First10EM / Broomedocs Journal club.

I have learned so much by just hanging out with Justin and reading the papers he digs up each month.  I hope you are learning the easy way too!  This month we have 10 papers for you with topics ranging from massive haemoptysis to “Tweeting drunk en route to ED”… apologies in advance as there is a lot of me harping on about ultrasound as the solution to everything!!

So sit back, grab a beverage and listen in for the JC with J&C.  As always the full text papers are available here [click on the titles to read] as is Justin’ written commentary on the articles.  Or pop over to the First10EM blog for more excellent ED stuff in general.


Qureshi F, Pestian J, Davis P, Zaritsky A. Effect of nebulized ipratropium on the hospitalization rates of children with asthma. The New England journal of medicine. 339(15):1030-5. 1998. PMID: 9761804
Combining ipratropium (Atrovent in Canada) with salbutamol for asthma patients is reflex for a lot of us, but sometimes it is good to remind ourselves why we do what we do. This is an double-blind RCT of 434 children in the emergency department with moderate to severe asthma exacerbations. All patients received 3 ventolin nebs over 1 hour and an oral steroid. They compared ipratropium (500mcg) nebulized with the 2nd and 3rd ventolin doses to saline. Overall, the rate of hospitalization was decreased in the ipratropium group (27% versus 37% with a borderline p value of 0.05, NNT=10). Comparing subgroups, there was no difference in patients with moderate asthma, but hospitalization was decreased with severe asthma. This is a good lesson for all of our therapies – the less sick you are, the less a benefit you will see. However, in this study there were a lot more severe patients than moderate patients (271 severe vs 169 moderate), which is not the normal distribution. Therefore, we might expect that the majority of non-trivial asthma patients seen in the emergency department will benefit from the addition of ipratropium to their beta-agonist.   [The Aussie Paeds Asthma Plan is here if you are interested]
Bottom line: Ipratropium decreases hospitalization rates in moderate to severe pediatric asthma exacerbations

#plastered and emergency room visits
Ranney ML, Chang B, Freeman JR, Norris B, Silverberg M, Choo EK. Tweet Now, See You In the ED Later? Examining the Association Between Alcohol-related Tweets and Emergency Care Visits. Academic emergency medicine. 23(7):831-4. 2016. PMID: 27062454
It probably won’t help you, but I love this look at big data to predict busier times in emergency departments. The authors searched a sample of Twitter posts for terms considered to be “alcohol related” and compared those tweets to the number of visits at a single high volume urban emergency department that were deemed to be alcohol related. There was a statistical association with the number of alcohol related tweets and the number of alcohol related visits (but not non-alcohol related visits.) In case you were wondering, the alcohol related keywords were “alcohol, beer, wine, cocktail, booze, drunk, partying, clubbing, wasted, plastered, and tipsy”. Although this data is far from definitive, I think social media is an interesting potential source of medical information.
Bottom line: If #plastered is trending, you might be in for a busy shift

It’s just a dislocated shoulder – aren’t you getting a little carried away with the ultrasound stuff, Justin?
Gottlieb M, Edwards H. BET 1: Utility of ultrasound in the diagnosis of shoulder dislocation. Emergency medicine journal : EMJ. 33(9):671-2. 2016. PMID: 27539978
One of the Best BET review series, this time looking at ultrasound in shoulder dislocation. They identified 2 relevant prospective observational studies, which were unsurprisingly small and heterogenous. Both papers report 100% sensitivity for both dislocation and reduction, but there were a few false positives. Of course, like all ultrasound studies, the reproducibility might depend on who is holding the probe and interpreting the images.
Bottom line: Ultrasound seems pretty good for shoulder dislocation. I use it routinely (both to confirm humeral head location and to guide intra-articular lidocaine) as long as I remember to bring the machine in the room before starting the procedure.

Blind art lines? Why do we even have an ultrasound machine?
Melhuish TM, White LD. Optimal wrist positioning for radial arterial cannulation in adults: A systematic review and meta-analysis. The American journal of emergency medicine. 2016. PMID: 27624367
Wrist positioning for radial artery cannulation is not a topic we normally think about in evidence based medicine. When placing art lines, we generally just do whatever our teachers showed us. That is why I like this small systematic review. They identified 5 papers totalling 500 patients that fit their inclusion criteria. All of the included studies were RCTs or crossover studies that used the same patient as their own control, and in general these studies were of high quality. The biggest problem with the studies is that they tend to use healthy volunteers, so it is not clear if the results would be the same in sicker patients, or patients already found to be difficult to cannulate. First pass success rate was better at 45 degrees wrist extension than 30 degrees (RR 0.77, 0.61-0.98, p=0.03) and also looked better at 45 degrees than 60 degrees, but not statistically so (RR 0.79, 0.56-1.12, p=0.19). The time to cannulation was also statistically faster at 45 degrees than either 30 or 60 degrees, but only by a few seconds.
Bottom line: If you are starting a radial arterial line, it appears that 45 degree of wrist extension is the best position for success

Nice guys finish last (in total lawsuits)
Smith DD, Kellar J, Walters EL, Reibling ET, Phan T, Green SM. Does emergency physician empathy reduce thoughts of litigation? A randomised trial. Emergency medicine journal : EMJ. 33(8):548-52. 2016. PMID: 27002161
Thanks to Clay Smith and EMTopics for bringing this article to my attention. This is a randomized, controlled trial of a convenience sample of 437 patients sitting in an emergency department waiting room. The participants were shown videos of discharge instructions between a physician and a patient (actor). In half of the videos, there were two specific empathic statements included. The statements were: “verbalisations that (1) the physician recognises that the patient is concerned about their symptoms and (2) the patient knows their typical state of health better than a physician seeing them for the first time and did the right thing by seeking evaluation”. The participants were then asked how likely they were to sue the doctor if there were to be a missed diagnosis. The empathy group was statistically less likely to think about suing, although I am not sure how important the magnitude of the difference is (mean Likert scale 2.66 vs 2.95, difference -0.29, 95% CI -0.04 to -0.54, p=0.0176). The big problem is, obviously, that fake decisions to sue after watching a video are going to be very different from real decisions to sue. But I don’t care so much about being sued (maybe that is the Canadian in me); displaying empathy towards patient complaints on one of the scariest days of their life is just part of being a decent human being (let alone a good doctor).
Bottom line: A few simple sentences probably go a long way towards displaying your empathy towards emergency department patients (and maybe prevent lawsuits).

The only certainties in life are death and taxes – and we could stand to make both a lot more humane
McEwan A, Silverberg JZ. Palliative Care in the Emergency Department. Emergency medicine clinics of North America. 34(3):667-85. 2016. PMID: 27475020
This is a good paper. It’s probably better to read the original than relying on my very brief summary. I include it because of some excellent tips on communication at the end of life. If you haven’t heard of the SPIKES model for breaking bad news, I talk about it in my post on breaking bad news. They also discuss the NURSE mnemonic for addressing emotions (and displaying empathy). Name the emotion: “You seem to be frustrated”. Understanding: summarizing what you are hearing from the patient. Respecting or acknowledging the individual’s emotion. Supporting the individual (either alone, or ideally with the helps of others such as social workers.). And finally, exploring: asking specific focused questions or expressing interest in something that was mentioned in order to deepen the empathic connection.
Bottom line: Palliative care and communication around death are essential skills in emergency medicine

Twist and shout
Rey-Bellet Gasser C, Gehri M, Joseph JM, Pauchard JY. Is It Ovarian Torsion? A Systematic Literature Review and Evaluation of Prediction Signs. Pediatric emergency care. 32(4):256-61. 2016. PMID: 26855342
A young girl presents with right lower quadrant pain. You order an ultrasound to look for appendicitis, but what else should be on your differential? Ovarian torsion is an important but difficult diagnosis to make in this setting. This is a systematic review that identified 14 studies (all retrospective, including a total of 663 patients) that looked at the diagnostic accuracy of history, physical, and imaging for ovarian torsion in pediatric patients (up to 21 years, but median age 11 years). Unfortunately, I can’t get anything out of this paper that will help me identify patients with torsion. For example, only 80% of patients had a sudden onset of pain; only 33% described the pain as severe; and 12% of patients didn’t even have abdominal tenderness on exam. No test was perfect. Ultrasound was better than CT, but still was only 79% sensitive. I include this to remind people to keep torsion on the differential, because it is easy sometimes to get caught in a rule out appendicitis algorithm in patients with RLQ pain, but I am not sure what else to take away. This might be helpful to you is you miss a torsion – because my read of the evidence is that it is standard of care to miss this diagnosis.
Bottom line: Pediatric ovarian torsion is a very difficult diagnosis to make

I might miss pediatric torsion, but I will find AAAs, right?
Metcalfe D, Sugand K, Thrumurthy SG, Thompson MM, Holt PJ, Karthikesalingam AP. Diagnosis of ruptured abdominal aortic aneurysm: a multicentre cohort study. European journal of emergency medicine : official journal of the European Society for Emergency Medicine. 23(5):386-90. 2016. PMID: 25969344
This is another study about diagnosis, this time about abdominal aortic aneurysm. It is a chart review of 85 consecutive patients diagnosed with AAA at 2 centres over a 6 month period. The major weakness of this data is that only patients in whom the diagnosis of AAA was made were included. Patients in whom the diagnosis was missed would not be included and those presentation might be different. Not surprisingly, AAA is a disease of older men; 82% were men and the median age was 76. About 20% of patients had symptoms for more than 1 day prior to presentation to the ED (so it doesn’t have to be acute onset). 60% had abdo pain, 54% had back pain, and 30% had both abdo and back pain. The most concerning number is the 10 (12%) patients with no pain at all, but it seems like these patients still had symptoms that should alert you to the diagnosis, with 7/10 having syncope or an altered level of consciousness in the department. 21% actually had the full triad of hypotension, palpable abdominal mass, and either back or abdo pain.
Bottom line: Although no single presentation is perfect, but if you have AAA on your radar for older patients with back pain, abdo pain, or syncope, you are in good shape.

How long until stethoscopes can only be found in museums?
Leuppi JD, Dieterle T, Koch G. Diagnostic value of lung auscultation in an emergency room setting. Swiss medical weekly. 135(35-36):520-4. 2005. PMID: 16323069 [free full text]
This is a neat little study that will probably ruffle a few feathers of those who value the more traditional physical exam. They took 243 consecutive patients presenting to the emergency department with chest symptoms and had the internal medicine registrars make a diagnosis first on history alone and then after lung auscultation (all before any testing was done). The final diagnosis was determined by hospital discharge letter. 41% of diagnoses were correct on history alone. Lung auscultation was essentially useless. It improved the diagnosis in only 1% of patients as compared to history, but it actually caused the registrars to change their mind to an incorrect diagnosis in 3% of patients. I don’t know how good these specific registrars were at auscultation, but I imagine at least as good as I am.
Bottom line: Not surprisingly, lung auscultation is not a highly accurate diagnostic tool.

Gottlieb M, Sharma V, Field J, Rozum M, Bailitz J. Utilization of a gum elastic bougie to facilitate single lung intubation. The American journal of emergency medicine. 2016. PMID: 27614374
I have discussed the management of massive hemoptysis before on the blog. One of the key steps in managing these patients is selectively intubating the one lung that isn’t bleeding. But how is the average emerg doc (without fancy equipment like a bronchoscope) supposed to ensure that the endotracheal tube ends up in the correct main stem? This is a small prospective, randomized, blinded cadaver study in which 2 individuals attempted to intubate either the right or left lung using a bougie. The bougie was either turned 90 degrees clockwise (for the right lung) or counterclockwise (for the left lung), advanced until hold up, and then a 6.0 cuffed tube was advanced over the bougie. Of a total of 45 placements, confirmed by a blinded assessor using a bronchoscope, they were successful at intubating the target lung 100% of the time (resulting in a 95% confidence interval of 90-100%). The technique is easy, so I don’t imagine that these two individuals would be a lot better at it than the average physician. They don’t tell me how long each procedure took, but it is possible that accuracy would decrease when pressured by falling sats and blood coming up the tube. However, the results are reassuring for those of us who include this step in our massive hemoptysis action plan.
Bottom line: A bougie is a helpful tool for selective lung intubation.